Electrosurgery and Argon Plasma Coagulation

My mother..my mentor..my teacher
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10/15/21-11/10/06
1
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The Art and Science
of Electrosurgery and Argon Plasma Coagulation
in Endoscopy
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Objectives
1. Discuss the basics of electricity and how it’s adapted for use in the
human body.
2. Describe how Electrosurgery is used therapeutically and the variables
that affect it.
3. Discuss how to provide safe electrosurgical care to patients.
4. Describe the basic principles and components of Argon Plasma
Coagulation (APC) and how it’s applied safely in clinical applications.
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How
cauterization durch
all started...
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Various tools were heated with fire -17th century.
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5
History
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- Hemostasis
durch
by cauterization
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1848
Galvanocautery
Christian Heinrich Erbe
von Bruns, MD
These devices were comprised of a metal wire,
heated by means of an electrical galvanic (direct)
current - used for coagulation and separation of
biological tissue and was referred to as
galvanocautery.
History
of Electrosurgery
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1923
Electrosurgical Unit (ESU),
in Europe
Christian Otto Erbe
1926
Electrosurgical Unit, in
the U.S.
William T Bovie, PhD
1971
“plasma scalpel” for
surgery
J.L. Glover, MD
1991
APC probes for flexible
endoscopy
ERBE GmbH
Harvey Cushing, MD
In 1978, Dr. Glover published an article on the use of thermal knives in comparison to other
modalities and stated, “There is no group of instruments in the surgical armamentarium that is
used as frequently and understood as poorly as Electrosurgery units….”
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We
are educated…but…
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1+ Day
21%
None
50%
10%
1/2 to 1 Day
19%
< 1 Hour
Electrocautery
vs. Electrosurgery…
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Direct Current
(Electrocautery)
…there is a difference
Electrocautery:
• Uses direct current.
• Often used inaccurately to describe “Electrosurgery”.
• Current does not enter the patient’s body – only the
heated wire tip comes in contact with tissue.
Alternating Current
(Electrosurgery)
Electrosurgery:
350 kHz
• Uses High-Frequency Alternating Current (AC).
• The AC Circuit must be completed: includes the
electrosurgical generator, active electrode, the
patient and return electrode.
Using
High-Frequencydurch
Alternating
Current
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54-880 MHz
TV
60 Hz
Household
100,000 Hz
Neuromuscular
stimulation
350,000 Hz
ESU’s
Therapeutic
Effect
550-1550 kHz
AM Radio
Fundamental
Properties
Electricity
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The Clinical Circuit is complete when current flows
from the ESU to the active electrode, to the patient,
to the pad, and back to the ESU.
Three variables are always present
during electrosurgery:
• Current – flow of electrons moving through
the electrical circuit, measured in amps (I).
• Voltage – electrical force pushing current
around the circuit, through varying degrees of
tissue resistance, measured I volts (V).
• Resistance (Impedance) – opposition to
current flow - literally the tissue being treated,
which has varying characteristics, measured in
ohms (R).
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12
German physicist Georg Simon Ohm
1789 - 1854
Ohm’s
Law
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Ohm’s Law is a set of mathematical formulas used
in electronics to calculate an unknown amount of
current, voltage or resistance.
• Ohm’s Law helps to predict how ESUs will
interact with tissue.
• The mathematical formula looks like this:
(I) Current = (V) Voltage
(R) Resistance
or
V=IXR
P (power)= V X I
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Adding
Power (W)durch
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Equation:
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Power is the amount of energy produced over
time and is a result of Voltage x Current.
W (Power) = (V) Voltage x (I) Current
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Types
of Electrosurgical
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Generators
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Constant
Voltage
• The voltage remains constant, to maintain consistent
tissue effect, regardless of changes in tissue
resistance (muscle, fatty tissue).
• The power (watts) automatically adjusts in response
to the tissue impedance/circuit variables.
Constant
Power
•
•
•
•
Watts (power) setting is chosen.
The Watts remain constant.
Voltage varies to maintain Watts.
All tissue is treated with same Wattage.
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Monopolar
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Bipolar
Circuit
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• Always seeks ground.
• Always seeks the path of
least resistance.
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Tissue
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Tissue Impedance Varies with Water Content
Scar Tissue, Lung,
Adhesions
Mesentary, Brain
Bowel,
Fat
Gallbladder
Liver, Oral Cavity
Muscle, Kidney, Eye
Least
to
Most
Resistance
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GI Endoscopy Paddurch
Placement
Pad Placement
• Well vascularized area
• Shortest circuit possible
• Optimum – on flank
• Alternatives –
Thigh or Arm
• Avoid Buttock placement
• Remove pads carefully to
prevent shearing of skin
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If the hair on the hand looks like this,
imagine the hair at the pad placement site…
The Dispersive Electrode Should NOT
Be Placed Over:
• Boney prominences
• Scar tissue – including Tattoos
• Skin/Scars over an implanted
metal prosthesis
• Hairy surfaces – clip if necessary
• Lotions or oils on skin
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Using
the Dispersive
Electrode
Correctly
Diagonal alignment of the dispersive electrode may
result
in higher current densities at the corner.
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Using
the Dispersive
Electrode
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The long side of the dispersive electrode must
face
the operating field.
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What
is Current Density?
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• Current Density is one of the most
important elements of electrosurgery.
• Basically, current density is the amount
of current concentration (intensity of heat
generation) at a given area.
• Thermal effect is created at the active
electrode.
Current
Density
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Which one offers more
Impedence?
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A Small Polyp?
…or a Larger One?
…all
shapes and sizes…many
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Endoscopy
Polypectomy
Techniques
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Cold
Biopsy
Hot
Biopsy
Cold
Snare
Hot
Snare
Saline Assisted
Polypectomy
Piecemeal
Resection
En bloc
Resection
Variables
Impacting
Tissue
Effectbearbeiten
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Physician
technique
Pad
placement
Patient variables:
age, body type,
hydration, tissue,
IED’s, etc.
Waveform: Cut
vs. Coag
Length of
activation
Type (size) of
Electrode
Type of Generator:
Constant voltage vs.
constant power
Variables
Impacting
Tissue
Effect
Anatomical
location
Electrosurgical
Thermal
Cells
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Temperature
Tissue Effect
104°F:
Reversible cellular trauma
120°F:
Irreversible cellular trauma
158°F:
Coagulation (Desiccation)
212°F:
Cutting
392°F:
Carbonization
Cutting
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•
Voltage quickly raises cell water temperature to the
boiling point.
•
Cell water turns to steam.
•
Cell explodes, separating from adjoining cells.
•
Cleavage plane is created = clinical “CUT”.
Note: For cutting to occur a minimum of 200 Vp is
required to get a spark.
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ENDO
CUT
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• ENDO CUT is a specialized waveform
which involves a fractionated cutting
mode with patented spark recognition
technology, characterized by alternating
cutting and coagulation cycles.
• Constant Voltage/Power Dosing
Technology.
• Yellow Pedal.
Akiho H, et al. Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis. World Journal
Gastroenterolgy. 2006;12:2086-8.
Monkemuller K, et al. State of the Art. Clinical Gastroenterology and Hepatology. 2009;7:641-652.
Frye L, et al. Quality of Polyps Resected by Snare Polypectomy: Does the Type of Electrosurgical Current Used Matter?
American Journal of Gastroenterology. 2006;101:2123-27.
Perini R, et al. Post sphincterotomy bleeding after microprocessor controlled electrosurgery. Gastrointestinal Endoscopy.
2005;61:53-7
Hopper, A. et al. Giant laterally spreading tumors of the papilla: endoscopic features, resection technique, and outcome.
Gastrointest Endosc. 2010;71:967-75.
Fanning, S. et al. Giant laterally spreading tumors of the duodenum: endoscopic resection outcomes, limitations, and caveats.
Gastrointest Endosc . 2012;75:805-12.)
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ENDOCUT
• Spark Recognition (arc regulation)
technology
• Patented algorithm capable of recognizing
microelectric arc production.
• Limits the “spark on” time to a few
milliseconds, depending upon the duration
chosen (the higher the duration, the longer
the spark on up to 12 ms).
• Rapid spark production with limited ‘on’ time
decreases thermal spread.
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Coagulation
Hemostasis due to
shrinking tissue
34
•
Waveform with spikes of high voltage,
followed by rest periods.
•
This allows the cellular proteins to
slowly denature (dehydrate).
•
Coagulation occurs.
Yellow
+ Blue IS NOT
Green
in electrosurgery…
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• COAGULATION (Blue) is completely
independent of CUT (Yellow).
• BLEND-CUT or ENDO CUT is a CUT
feature (Always Yellow).
• Settings on one side do not effect the
other.
Like a set of rail tracks
running into infinity…
they never meet.
Argon Plasma Coagulation
(APC)
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APC is a non-contact monopolar application for
hemostasis and thermal destruction
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What is Argon Plasma?
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Argon
•
•
•
•
•
•
Nobel gas
Present in air (≈ 1%)
Non-flammable
Non-toxic
Ionizes easily
Heavier than air
Plasma
• Ionized, electrically
conductive gas
• Ionization by way of
high voltages
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Argon-one
of the Nobel
durch gases
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38
Argon Plasma Coagulation
- APC
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The voltage required
for ionization of gas
is ≈ 4000 volts
Argon gas
Argon plasma with arc beam
APC is a monopolar application in which HF electrical energy is transferred to
the target tissue using ionized (conductive) argon gas (plasma), without the
electrode coming in contact with the target tissue.
Argon Plasma Coagulation
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En face APC
Ar
Ar
Ar
Tangential APC
Ionized Argon Gas
Argon Plasma Coagulation offers particular advantages for endoscopic applications
as it can be applied en face or tangentially, enabling less accessible areas to be
easily treated.
Argon
Plasma Coagulation
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APC Advantages:
• Non-contact application.
• Smoke is reduced.
• Thinner, more flexible eschar.
• Widespread areas can be treated.
• Applications can be –
• Axial
• Radial
• Retroflexed
• Circumferential
Argon
Plasma Coagulation
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Using APC:
• Purge probe at least twice before
placing in the scope channel.
• Advance the tip of the probe until the
first black line is visible on the monitor;
at this point, you can slightly pull the
probe back to facilitate scope
articulation, depth perception, and
treatment as needed.
Probe tip
First Black Line
• APC probe tip must always remain in
the clinicians field of vision.
• Activate only when the tissue being
treated is within the field of view.
• Leave the probe stationary – move the
SCOPE.
• Proximity to tissue: 1 - 5 mm.
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Argon
Plasma Coagulation
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Application techniques:
Static:
• Probe is focused in one
single area.
• Thermal penetration will
increase over time.
• Carbonization and
vaporization can occur
with long activations in
one area.
• For superficial
treatment, short
activation times of 1-2
seconds are used.
Dynamic:
• Probe is moved with
paintbrush-like strokes
over the target area
while observing the
target tissue effect.
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• ..\Desktop\ERBE.VIO.TOMMYGUN.GAVE.mpg
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Argon Plasma Coagulation
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APC thermal tissue effect depends on several factors
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Duration
of Activation
• When the application time over the
same area is increased, the depth
of the tissue being affected will
increase.
Fig. 12: Depth effect depending on the
duration of activation with the APC modes in a
bovine liver. Testing was performed with an ESU
(VIO® 300 D Model)/APC (APC™ 2 Model) System
along with an A-type (Straight Fire) APC probe,
O.D. 2.3 mm. Also, the application was vertical
and the probe distance was 5 mm.
• The physician should treat with an
activation time to correspond with
the desired thermal effect and
anatomical location.
Power
Setting or Effect
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In general:
•
Lower output settings –
are used for treatment of very
small superficial areas, or in
applications with very thinwalled tissue structures.
•
Higher output settings –
are used for treatment when
devitalization is required, or
for the reduction of tissue.
Probe
Distance
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Probe distance can influence
thermal tissue effect based on
the mode chosen:
– FORCED APC
– PULSED APC
• Effect 1
• Effect 2
– PRECISE APC
Another important factor involving thermal
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effect
is the mode durch
chosen…
FORCED
PULSED EFFECT 1
• Constant beam
• Higher energy output
one pulse/second.
• Areas of Application:
• Rapid devitalization
of target tissue
• Hemostasis of acute
bleeding
• Areas of Application:
• “Static” applications
used for more
focused treatment of
smaller, superficial
areas in need of
hemostasis.
PULSED EFFECT 2
PRECISE
• 16 pulses/second with
a lower energy output
per pulse.
• Superficial coagulation
effect using a lowenergy output.
• Areas of Application:
• “Dynamic”
applications used for
the treatment of
diffuse, superficial
hemostasis.
• Areas of Application:
• Superficial
hemostasis in
thermosensitive
areas and/or within
thin-walled structures.
• Devitalization and
reduction of lesions
or tissue remnants
that are superficial in
nature.
• When maintaining the
probe distance from
the tissue is difficult,
e.g., enteroscopic
intervention due to
plasma regulation.
®
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Modes - PRECISE APC Klicken bearbeiten
Eickoff A. et al. Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding
Gastrointestinal Angiodysplasia - a Retrospective Evaluation. Z Gastroenterol 2011; 49:195–200.
®
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Modes
- PRECISE durch
APC Klicken bearbeiten
Areas of Application:
• Superficial hemostasis.
• Thermosensitive areas and/or
within thin-walled structures.
• Devitalization and reduction of
lesions or tissue remnants that are
superficial in nature.
• In situations where maintaining the
probe distance from the tissue is
difficult, e.g., enteroscopic
intervention.
Clinical Video
Angiodysplasia
PRECISE APC Effect 5
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APC
Probes
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There are differences:
• Diameter
• Length
• Shape of the probe’s outlet:
• Axial direction
• Side fire
• Circumferential
Black rings:
• 1cm apart (10mm)
1cm
Marking rings
Connector
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Clinical
Applicationsdurch
- APCKlicken bearbeiten
Gastroenterology Uses reported in Clinical Literature
• Radiation Induced Proctopathy
• Watermelon Stomach (GAVE)
• Treatment of Residual Adenomatous Tissue
• Stent Shortening (e.g. migrated stents)
• Strictures
• Exophytic Benign or Malignant Tumors
• Oozing from Vascular Lesions (e.g. Angiodysplasias,
Arteriovenous Malformations (AVMs), Telangiectasias)
Clinical
Applicationsdurch Klicken bearbeiten
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Residual Tumor Ablation
1. Adenoma of
Cecum
2. Adenoma Injected
3. Adenoma Snared
(piecemeal)
4. Ablation of Bed
with APC
Long term clinical study results show 50% reduction in re-growth
of adenomatous polyps after tissue treatment with APC.
Brooker J, Saunders B, et al. Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of
large sessile colonic polyps: A randomized trial and recommendations. Gastrointestinal Endoscopy 2002; 55:371-375.
Regula, J. Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas: Long-Term Follow
Up Study. Endoscopy, 2003.
Clinical
Applications
- APC
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Gastroenterology Uses found in Clinical Literature
References:
1. “The role of endoscopy in ampullary and duodenal adenomas”. Gastrointestinal Endoscopy; 2006: Vol. 64, No 6.
2. Brooker, J. Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps: a randomized trial and
recommendations. Gastrointestinal Endoscopy, 2002.
3. Buyukberber, Mehmet. APC in the treatment of hemorrhagic radiation proctitis. Turk J Gastroenterol, 2005.
4. Dulai, Gareth. Treatment of Water Melon Stomach. Current Treatment Options in Gastroenterology, 2006.
5. Eickhoff, A, et al. Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction: effectiveness
of the new pulsed APC versus forced APC. Endoscopy 2007: 39: 637-642. Ferreira, L, et al. Post-Sphincterotomy Bleeding: Who,
What, When, and How. American Journal of Gastroenterology. 2007.
6. Eickhoff, A, et al. Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy. Surg
Endosc. 2007.
7. Fujishiro, M. Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection. Surg Laparosc Endosc
Percutan Tech; 2006.
8. Fukami, N. Endoscopic treatment of large sessile and flat colorectal lesions. Current Opinions in Gastroenterology. 2006:22:54-59.
9. Fukatsu, H, et al. Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation, especially with regard to
postoperative anatomic factors. Surg Endosc. 2008;22:717-23.
10. Garcia, A, et al. Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas. Rev Esp Enferm Dig.
2004:96:315-321.
11. Herrera S, et al. The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia
lesions in patients admitted for GI hemorrhage. Gastrointestinal Endoscopy 2008.
12. Horiuchi, A, et al. Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla. Clin
Gastroenterol Hepatol. 2007;5:1113-8.
13. Ifadhli A, et al. Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy. Can
J Gastroenterol 2008;22:129-132.
14. Kitamura, Tadashi. Argon plasma coagulation for early gastric cancer: technique and outcome. Gastrointestinal Endoscopy, 2006.
15. Kwan, V. APC in the Management of Symptomatic GI Vascular Lesions. American Journal of Gastroenterology. 2006.
16. Lecleire, S, et al. Bleeding gastric vascular ectasia treated by argon plasma coagulation: a comparison between patients with and
without cirrhosis. Gastrointestinal Endoscopy. 2008:67.
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Clinical
Applicationsdurch
- APCKlicken bearbeiten
Gastroenterology Uses found in Clinical Literature
References:
17. Manner, H, et al. Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper
gastrointestinal tract. Digestive and Liver Disease. 2006.
18. Norton, I, et al. A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation
Waveforms. Clinical Gastroenterology and Hepatology. 2005; 3:1029-1033.
19. Norton, I, et al. Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury. Gastrointestinal
Endoscopy. 2002:Vol 56, No 1.
20. Olmos, Jorge. APC for prevention of recurrent bleeding from GI angiodysplasias. Gastrointestinal Endoscopy, 2004.
21. Ortner, M, et al. Endoscopic Interventions for Preneoplastic and Neoplastic Lesions: Mucosectomy, Argon Plasma Coagulation, and
Photodynamic Therapy. Digestive Diseases. 2002;20 :167-172.
22. Perini, Rafael. Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery. Gastrointestinal Endoscopy. 2005.
23. Regula, J. Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas: Long-Term Follow-Up Study.
Endoscopy, 2003.
24. Repici, A. Endoscopic polypectomy: techniques, complications and follow-up. Tech Coloproctol. 2004; 8: S283-S290.
25. Rerknimitr, R. Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator. Cardio Vascular and Interventional Radiology,
2006.
26. Ross, A. Flat and Depressed Neoplasms of the Colon in the Western World. American Journal of Gastroenterology. 2006.
27. Schubert, D. Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination
with diathermy. Surg Endosc; 2003:17:1579-1582.
28. Soctikno, R, et al. Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults.
JAMA. 2008: Vol 299, No 9.
29. Vargo, John. Clinical Applications of APC. Gastrointestinal Endoscopy, 2004.
30. Zlatanic, J, et al. Large sessile colonic adenomas: use of argon plasma coagulator to supplement piecemeal snare polypectomy.
Gastrointestinal Endoscopy; 1999: Vol. 49, No. 6.
Clinical
Applications
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Pulmonary Uses reported in Clinical Literature
•
•
•
•
Granulation Tissue
Bleeding/Hemoptysis
Exophytic Tumors
Stent Over-growth/In-growth
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Clinical
Applications
durch
- APC
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Pulmonary Uses found in Clinical Literature
References:
1. Bergler, Wolfgang, Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation. Journal of
Laryngology and Otology. 1997.
2. Bolligner, CT, et al. Therapeutic bronchoscopy with immediate effect: laser, electrocautery, argon plasma
coagulation and stents. European Respirartory Journal. 2006: 27:1258-1271.
3. Capaccio, P, et al. Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma.
American Journal of Otolarynogology. 2002: Vol 23, No 4.
4. Crosta, C et al. Endoscopic argon plasma for palliative treatment of malignant airway obstructions: early results
in 47 cases. Lung Cancer. 2001: 33: 75-80.
5. Lee, P, et al. Advances in Bronchoscopy-Therapeutic Bronchoscopy. JAPI. 2004: Vol 52.
6. Morice, Roldofo. Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway
Obstruction. Chest. 2001.
7. Orino, K, et al. Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids:
Report of a Case. Anticancer Research. 2004: 24:4073-4078.
8. Sheski, F. Endobronchial Electrosurgery. Seminars in Respiratory and Critical Care Medicine. 2004: Vol, 25,
No 4.
9. Sohrab, S. Management of Central Airway Obstruction. Clinical Lung Cancer. 2007.
10. Sutedja, G. Endobronchial Electrocautery and Argon Plasma Coagulation. Prog Respir. 2000: Vol 30.
11. Tremblay, A. Endobronchial electrocautery and Argon Plasma Coagulation: A Practical Approach. Can Respir.
2004.
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Clinical
Safety Considerations…
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…let’s discuss further.
59
Clinical
Safety
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Important Considerations for Endoscopy
• Use the lowest possible output
settings, as well as the shortest
activation times.
• Confirm gas flow (with APC use) and
settings prior to activation.
• Continuously monitor for signs of overdistention.
•
Brief and repeated aspirations should be
routinely performed throughout the procedure.
Clinical
Safety
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Important Considerations for Endoscopy
APC is a non-contact modality
If an ‘Axial’ Probe is too close to the tissue,
an undesirable thermal effect or
submucosal emphysema may occur.
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Clinical
Safety
Important Considerations for Endoscopy
Avoid APC activation in close
proximity of metal objects
• The APC probe should not be
activated if the tip is in close
proximity to metal objects.
• Unintended thermal injury of
the surrounding tissue may
occur.
• Metal objects may receive
unintentional damage.
• Exceptions - “trimming” of
migrated metal stents.
Clinical
Safety
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The Importance of Bowel Preps…
• Incomplete Preps or enema-only preps
for Flexible Sigmoidoscopy increases
the risk for bowel explosions.
• Bowel explosions can occur with ANY
monopolar electrosurgery (e.g. snare,
APC, hot biopsy) when combined with
hydrogen and methane gases in a dirty
colon.
• Patients should be fully prepped.
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Quiz:
Who’s has the
durch
most
Klicken
gas? bearbeiten
64
Clinical
Safety - Oxygen
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Preventative Measures to Avoid Combustion
Maintain oxygen concentration at safe levels:
• Conscious Sedation Patient
Supplemental nasal cannula
O2 at 3 L/M or LOWER.
Mask delivery is considered high risk.
• Intubated Vent Patient
FiO2 Concentration should
be reduced to 40% or less.
• Activation
Activate APC during the patient’s
exhalation phase, or during apnea.
Combustion requires a heat source, fuel, and oxygen,
all components of the fire triangle.
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• Introduced in the 1980’s:
– Return Electrode Monitoring (REM)
– Aspen Return Monitoring (ARM)
• Introduced in the early 1990’s:
– Neutral Electrode Safety System (NESSY)
• Introduced in 2012:
– Neonatal Monitoring
According to AORN guidelines, return-electrode contact quality monitoring
(RECQM) should be furnished on general purpose electrosurgical units.
2013 Perioperative Standards and Recommended Practices, AORN.
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Dispersive
Electrodes
• According to AORN:
• Dispersive electrode site burns are the
most reported electrosurgical injury.
• With improved technology and the use of
safety features, pad-site burns have
decreased from 50 to 100 in the late
1970’s to one to two per month in 2007.
• Return electrode quality monitoring must
be furnished.
• Dual pads should be used.
2013 Perioperative Standards and Recommended
Practices, AORN.
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•
MONO Foil or Single pad:
– Performs only completion of
the electrical circuit.
– The current density of the
pad edges is not measured.
– The correct orientation of the
pad is not measured.
•
DUAL Foil or Split Pad:
– Completes the electrical circuit.
– Disperses the current density.
– Engages the safety system of
the unit to monitor for high
current density (and correct
®
orientation with NESSY ).
Mono Pads bypass the pad safety system
of generators…
Always recommended
Dispersive
Electrode
Reminders
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• Open the pad only when ready to use.
• Pads cannot be repositioned; always
replace the pad.
• Remove pad SLOWLY to prevent skin
shearing.
• Always check the pad placement
before activation of the ESU.
• Do not “test” instruments on the pad,
e.g. snares, hot forceps.
Clinical
Safety
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Jewelry Removal:
Navel and genital jewelry
• ESU Manufacturers
and Clinical
can be in the circuit,
increasing risk of burns
Guidelines recommend
removal
of ALL pierced and non-pierced
jewelry, due to the risk of burn if
within the electrical circuit.
• Removal helps to:
− Avoid Burns
− Avoid accidental injury
− Lower staff liability
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Challenge?
71
Clinical Safety – Additional Challenges
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Body modifications require special attention
for maintenance of the patients skin integrity…
Trans-dermal and micro-dermal implants –
thin metal posts protruding through skin
Sub-dermal implants
Additional risks are posed due to:
- Patient positioning
- Patient transfers
- Electrosurgery use and pad placement
Implanted
Electronic
Devices
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Implanted Electronic Devices (IEDs) are battery operated devices placed
within a patient’s body to treat a physiological defect or to replace a
sensory function –
•
Cardiac
–
–
–
•
Deep brain stimulators
Spinal cord stimulators
Vagal nerve stimulators
Programmable ventricular shunts
Implantable Hearing Devices
Cochlear Implants
Auditory Brainstem Implant (ABI)
Bone-conduction stimulators
Pacemakers
Internal Cardiac Defibrillators (ICDs)
Ventricular Assistive Devices (VADs)
Neurostimulators
–
–
–
–
•
•
Implanted Infusion Pumps
•
Osteogenic (Bone-growth) Stimulators
•
Gastric Electronic Pumps
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Pre-planning is crucial…
• Pre-procedure knowledge of IED patients
allows time for adequate planning:
•
•
Determine the type and location of the device.
Contact the implanting physician to determine • Last device evaluation.
• Any specific pre-op/post-op orders for the
device.
• Consider having a policy in place specific to IED
patients:
•
•
•
Utilize anesthesia and manufacturer device-specific
guidelines as warranted to assist with establishing facility
protocols and guidelines for care of IED patients.
Contact appropriate device representatives and arrange
presence during procedures, based on protocols.
Notify the physician, anesthesia and other team members
in advance of an IED patient.
Implanted
Electronic
Devices
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“AORN Guidance Statement: Care of the Perioperative Patient
With an Implanted Electronic Device”
AORN offers guidelines for
Implanted Electronic Devices
Safety
Considerations
– IED’s
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Electrosurgical Safety for Patients with IED’s
•
Use Bipolar when possible.
•
Keep 15 cm between the active
electrode and any EKG electrode.
•
Have resuscitation equipment at the
ready – DOCUMENT.
•
Have the device clinical support line
available.
•
Contact the IED manufacturer for
specific deactivation recommendations.
Safety
Considerations
– IED’s
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Electrosurgical Safety for Patients with IED’s
If the physician must use Monopolar current:
• Apply the dispersive electrode close to
the operative site, but as far away from
the IED as possible (eg. for patients with
pacemakers/ICD’s, place on the opposite
lower extremity to draw current away
from the device).
• Use the lowest settings possible.
• Use the shortest possible activations.
• If the ICD is deactivated, re-establish
integrity of the device post-procedure.
Neuromuscular
Stimulation
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• Causes of current demodulation:
• Loose wires/cables
• Damaged internal cable wires
• Broken adapters
• Preventive Measures:
• Replacement schedule for cables.
• Visual inspection for insulation
damage of electrosurgical cables.
• Visually and physically check
cables for damage.
Reference: Hazard Report Internal Wire Breakage in Reusable
Electrosurgical Active Electrode Cables May Cause Sparking
and Surgical Fires. Health Devices 2009:228-9.
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Who is responsible for determining settings
for procedures?
ESU Risk Management in Endoscopy
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Equipment Obsolescence
•
Specific ESU models become obsolete when they are no longer
manufactured, serviced, or supported.
•
Many ESUs in GI are obsolete.
•
Manufacturers are required to notify customers of product obsolescence.
•
JCAHO surveyors have evaluated and cited institutions for equipment
obsolescence.
ESU
Risk Management
Endoscopy
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Equipment Standardization
• Is your lab diagnostically standardized or therapeutically standardized???
• ESU’s from multiple manufacturers does not mean your lab is standardized.
• Multiple ESU types and models means multiple operating systems, voltage
platforms, and electrosurgical technologies.
Summary
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• The “art” of therapeutically utilizing high-frequency (HF)
electricity/electrosurgery within the hollow lumen of the GI tract
requires a fundamental working knowledge of the scientific
principles involved in order to optimize clinical outcomes while
minimizing risks.
• It is important for the clinician to understand the basic principles
and properties of electrosurgery and APC and how it’s adapted
for clinical use.
• In addition, staying well-informed on the current standards and
recommended practices for clinical safety, e.g. SGNA and
AORN, enhances our ability to make critical decisions and to
promote optimal patient outcomes.
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Thank you
for your attention.
Copyright © 2014 ERBE USA, Inc.
ERBE Elektromedizin GmbH
Waldhörnlestraße 17
72072 Tübingen
Deutschland
Telefon +49 7071 755-0
Telefax +49 7071 755-179
[email protected]
www.erbe-med.com
ERBE USA, Inc.
2225 Northwest Pkwy
Marietta, GA 30067
Tel: 800.778.ERBE
www.erbe-usa.com